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Madison County,

Montana Community Health Services Development

Community Health Needs Assessment Report

Survey conducted by

Madison Valley Medical Center

Ennis, Montana

In cooperation with

The Montana Office of Rural Health &

The National Rural Health Resource Center

September 2014

1


Community Health Needs Assessment

Table of Contents

I. Introduction ............................................................................................................................................. 2

II. Health Assessment Process .................................................................................................................... 2

III. Survey Methodology ............................................................................................................................. 2

IV. Survey Respondent Demographics ....................................................................................................... 5

V. Survey Findings ..................................................................................................................................... 9

VI. Key Informant Interview Methodology .............................................................................................. 47

VII. Summary of Key Informant Interview Findings ............................................................................... 48

VIII. Summary .......................................................................................................................................... 50

Appendix A – Steering Committee Members ........................................................................................... 51

Appendix B – Public Health and Special Populations Consultation ........................................................ 52

Appendix C – Survey Cover Letter .......................................................................................................... 54

Appendix D – Survey Instrument ............................................................................................................. 55

Appendix E – Responses to Other and Comments ................................................................................... 61

Appendix F – Key Informant Interview Questions................................................................................... 65

Appendix G – Key Informant Interview Notes ......................................................................................... 66

Appendix H – Secondary Data ................................................................................................................. 72

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Community Survey & Interviews

Summary Report

September 2014

I. Introduction

Madison Valley Medical Center (MVMC) is a 10-bed Critical Access Hospital with a rural

health clinic, and is a public non-profit organization based in Ennis, Montana. Madison Valley

Medical Center is the only hospital and clinic in the Madison Valley Hospital District and serves

a resident population of approximately 3,451 people. The medical center provides primary care

to district residents and is a designated trauma receiving facility with a provider available for

emergency services. Madison Valley Medical Center participated in the Community Health

Services Development (CHSD) Project, a Community Health Needs Assessment (CHNA),

conducted by the Montana Office of Rural Health and the National Rural Health Resource

Center (NRHRC) in Duluth, Minnesota. Community involvement in steering committee

meetings and key informant interviews enhanced the community’s engagement in the assessment

process.

In the spring of 2014, Madison Valley Medical Center’s service area was surveyed about its

healthcare system. This report shows the results of the survey in both narrative and chart

formats. A copy of the survey instrument is included at the end of this report (Appendix D).

Readers are invited to familiarize themselves with the survey instrument and the subsequent

findings. The narrative report touches on the highlights while the charts present data for virtually

every question asked. Please note: we are able to compare some of the 2014 survey data with

data from a previous survey conducted in 2011. If any statistical significance exists, it will be

reported. The significance level was set at 0.05.

II. Health Assessment Process

A Steering Committee was convened to assist Madison Valley Medical Center in conducting the

CHSD assessment process. A diverse group of community members representing various

organizations and populations within the community (ex. public health, elderly, uninsured) came

together in May 2014. For a list of all Steering Committee members and their affiliations, see

Appendix A. The Steering Committee met twice during the CHSD process; first to discuss health

concerns in the community and offer their perspective in designing the survey instrument and

again to review results of the survey and key informant interviews.

III. Survey Methodology

Survey Instrument

In May 2014, surveys were mailed out to the residents in Madison Valley Medical Center’s

service area. The survey was based on a design that has been used extensively in the states of

3

Washington, Wyoming, Alaska, Montana, and Idaho. The survey was designed to provide each

facility with information from local residents regarding:

Demographics of respondents

Hospitals, primary care providers, and specialists used plus reasons for selection

Local healthcare provider usage

Services preferred locally

Perception and satisfaction of local healthcare

Sampling

Madison Valley Medical Center provided the National Rural Health Resource Center with a list

of outpatient and inpatient admissions. Those zip codes with the greatest number of admissions

were selected to be included in the survey. A random list of 740 residents was then selected

from Prime Net Data Source. Residence was stratified in the initial sample selection so that each

area would be represented in proportion to the overall served population and the proportion of

past admissions. (Note: although the survey samples were proportionately selected, actual

surveys returned from each population area varied which may result in slightly less proportional

results.)

Additionally, six key informant interviews were conducted to identify the motives of local

residents when selecting healthcare providers and to discover reasons why people may leave the

Ennis area to seek healthcare services. It was intended that this research would help determine

the awareness of local programs and services, as well as the level of satisfaction with local

services, providers, and facilities.

Information Gaps

Data

It is a difficult task to define the health of rural and frontier communities in Montana due to the

large geographic size, economic and environmental diversity, and low population density.

Obtaining reliable, localized health status indicators for rural communities continues to be a

challenge in Montana.

There are many standard health indices used to rank and monitor health in an urban setting that

do not translate as accurately in rural and frontier areas. In the absence of sufficient health

indices for rural and frontier communities in Montana, utilizing what is available is done with an

understanding of access to care in rural and frontier Montana communities and barriers of

disease surveillance in this setting.

The low population density of rural and frontier communities require regional reporting of many

major health indices including chronic disease burden and behavior health indices. The Montana

BRFSS [Behavioral Risk Factor Surveillance System], through a cooperative agreement with the

Center for Disease Control (CDC), is used to identify regional trends in health-related behaviors.

The fact that many health indices for rural and frontier counties are reported regionally makes it

impossible to set the target population aside from the five more-developed Montana counties.

4

Limitations in Survey Methodology

A common approach to survey research is the mailed survey. However, this approach is not

without limitations. There is always the concern of non-response as it may affect the

representativeness of the sample. Thus, a mixture of different data collection methodologies is

recommended. Conducting community focus groups and key informant interviews in addition to

the random sample survey allows for a more robust sample and, ultimately, these efforts help to

increase the community response rate. Partnering with local community organizations such as

public health, community health centers, and senior centers, just to name a few, helps to reach

segments of the population that might not otherwise respond to a survey or attend a focus group.

Survey Implementation

In May 2014, the community health services development survey, a cover letter from the

National Rural Health Resource Center with Madison Valley Medical Center’s Chief Executive

Officer’s signature on Madison Valley Medical Center letterhead, and a postage paid reply

envelope were mailed to 740 randomly selected residents in the hospital’s service area. A news

release was sent to local newspapers prior to the survey distribution announcing that Madison

Valley Medical Center would be conducting a community health services survey throughout the

region in cooperation with the Montana Office of Rural Health.

One hundred sixty-five surveys were returned out of 740. Of those 740 surveys, 62 were returned

undeliverable for a 24% response rate. From this point on, the total number of surveys will be

out of 678. Based upon the sample size, we can be 95% confident that the responses to the

survey questions are representative of the service area population, plus or minus 6.61%.

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IV. Survey Respondent Demographics

A total of 740 surveys were distributed amongst Madison Valley Medical Center’s service area.

One hundred and sixty-five were completed for a 24% response rate. The following tables

indicate the demographic characteristics of the survey respondents. Information on location,

gender, age, and employment is included. Percentages indicated on the tables and graphs are

based upon the total number of responses for each individual question, as some respondents did

not answer all questions.

Place of Residence (Question 32)

While there are some large differences in the percentages below, the absolute differences are

small. The returned surveys are skewed toward the Ennis population which is reasonable given

that this is where most of the services are located.

2011 2014

Area Zip code Count Percent Count Percent

Ennis 59729 150 64.1% 111 69.8%

McAllister 59740 35 15.0% 19 11.9%

Cameron 59720 18 7.7% 14 8.8%

Pony 59747 2 0.9% 3 1.9%

Norris 59745 4 1.7% 3 1.9%

Virginia City 59755 7 3.0% 3 1.9%

West Yellowstone 59758 5 2.0% 3 1.9%

Alder 59710 2 0.9% 2 1.3%

Harrison 59735 11 4.7% 1 0.6%

TOTAL 234 100% 159 100%

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Gender (Question 33)

2014 N= 165

2011 N= 252

Of the 165 surveys returned, 67.3% (n=111) of survey respondents were female, 30.9% (n=51)

were male, and 1.8% (n=3) chose not to answer this question. The survey was distributed to a

random sample consisting of 50% women and 50% men. It is not unusual for survey

respondents to be predominantly female, particularly when the survey is healthcare-oriented

since women are frequently the healthcare decision makers for families.

36.5%

59.5%

4%

30.9%

67.3%

1.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Male Female No answer

Gender

2011 2014

7

Age of Respondents (Question 34)

2014 N= 161

2011 N= 241

Thirty-five percent of respondents (n=56) were between the ages of 56-65. Twenty-nine percent

of respondents (n=47) were between the ages of 66-75 and 13.7% of respondents (n=22) were

between the ages of 76-85. This statistic is comparable to other Critical Access Hospital (CAH)

demographics. The increasing percentage of aging residents in rural communities is a trend

which is seen throughout Montana and will likely have a significant impact on the need for

healthcare services during the next 10-20 years. However, it is important to note that the survey

was targeted to adults and therefore, no respondents are under age 18. Older residents are also

more invested in healthcare decision making and therefore, are more likely to respond to

healthcare surveys, as reflected by this graph.

0.4%

6.7% 6.7%

11.2%

33.2%

22.8%

14.9%

4.1%0.6%

4.3%5.6%

10.6%

34.8%

29.2%

13.7%

1.2%

0%

10%

20%

30%

40%

18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 66 - 75 76 - 85 86+

Age of Respondents

2011 2014

8

Employment Status (Question 35)

2014 N= 155

2011 N= 231

Fifty-four percent of respondents (n=83) reported being retired while 25.9% (n=40) work full

time and 11% (n=17) work part time. Respondents could select all that apply so percentages do

not equal 100%. Ten respondents chose not to answer this question.

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V. Survey Findings – Community Health

Impression of Community (Question 1)

2014 N= 151

2011 N= 232

Respondents were asked to indicate how they would rate the general health of their community.

Forty-six percent of respondents (n=70) rated their community as “Healthy.” Forty-four percent

of respondents (n=66) felt their community was “Somewhat healthy” and 6% (n=9) felt their

community was “Unhealthy.” Fourteen respondents chose not to respond to this question.

1 Significantly fewer 2014 respondents rated their community as "very healthy" or "healthy" than in

2011.

10

Health Concerns for Community (Question 2)

2014 N= 165

2011 N= 252

Respondents were asked what they felt the three most serious health concerns were in their

community. The number one health concern identified by respondents was “Alcohol abuse/

substance abuse” at 63% (n=104). “Cancer” was also a high priority at 38.2% (n=63) then

“Obesity/overweight” at 29.1% (n=48). Respondents were asked to pick their top three serious

health concerns so percentages do not equal 100%.

2011 2014

Health Concern Count Percent Count Percent

Alcohol abuse/substance abuse 162 64.3% 104 63.0%

Cancer 86 34.1% 63 38.2%

Overweight/obesity1 44 17.5% 48 29.1%

Motor vehicle accidents2 35 13.9% 36 21.8%

Tobacco use 53 21.0% 30 18.2%

Heart disease 32 12.7% 28 17.0%

Depression/anxiety Not asked in 2011 24 14.5%

Diabetes 33 13.1% 20 12.1%

Lack of exercise 44 17.5% 19 11.5%

Lack of senior services 23 9.1% 19 11.5%

Mental health issues 13 5.2% 16 9.7%

Recreation related accidents/injuries 21 8.3% 14 8.5%

Lack of access to healthcare 25 9.9% 11 6.7%

Lack of dental care 12 4.8% 11 6.7%

Stroke 6 2.4% 10 6.1%

Child abuse/neglect 9 3.6% 9 5.5%

Domestic violence 16 6.3% 8 4.8%

Lack of vision care 7 2.8% 5 3.0%

Work related accidents/injuries 7 2.8% 5 3.0%

Other 5 2.0% 7 4.2% 1Significantly more respondents indicated that overweight/obesity as a serious health concern in 2014

than in 2011. 2Significantly more 2014 respondents cited motor vehicle accidents as a serious community health

concern than in 2011.

“Other” comments:

- Affordable healthcare for seniors

- Health education

- Highway accidents

- Hypertension

- Lack of access to local specialists and specialized services

- Lack of health education

- Preventative care

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Components of a Healthy Community (Question 3)

2014 N= 165

2011 N= 252

Respondents were asked to identify the three most important things for a healthy community.

Sixty-four percent of respondents (n=105) indicated that “Access to healthcare and other

services” is important for a healthy community. “Good jobs and healthy economy” was the

second most indicated component at 40.6% (n=67) and third was “Healthy behaviors and

lifestyles” at 37% (n=61). Respondents were asked to identify their top three choices, thus the

percentages do not add up to 100%.

2011 2014

Important Component Count Percent Count Percent

Access to healthcare and other services 164 65.1% 105 63.6%

Good jobs and a healthy economy 92 36.5% 67 40.6%

Healthy behaviors and lifestyles 109 43.3% 61 37.0%

Strong family life 62 24.6% 47 28.5%

Affordable housing1 32 12.7% 41 24.8%

Religious or spiritual values 37 14.7% 34 20.6%

Clean environment 62 24.6% 34 20.6%

Low crime/safe neighborhoods 60 23.8% 33 20.0%

Good schools 59 23.4% 28 17.0%

Community involvement 34 13.5% 16 9.7%

Tolerance for diversity 10 4.0% 10 6.1%

Low death and disease rates 20 7.9% 10 6.1%

Parks and recreation 18 7.1% 6 3.6%

Arts and cultural events 11 4.4% 3 1.8%

Low level of domestic violence 7 2.8% 2 1.2%

Other 1 0.4% 1 0.6% 1Affordable housing was cited significantly more often in 2014 than in 2011.


- Senior center

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Survey Findings – Awareness of Services

Overall Awareness of Health Services (Question 4)

2014 N= 163

2011 N= 241

Respondents were asked to rate their knowledge of the health services available at Madison

Valley Medical Center. Fifty-eight percent (n=95) of respondents rated their knowledge of health

services as “Good.” Twenty-two percent (n=36) rated their knowledge as “Excellent” and 16.6%

of respondents (n=27) rated their knowledge as “Fair.” Two respondents chose not to answer this

question.

1Respondents rated their knowledge of health services as either “Excellent” or “Good” significantly

more often in 2014 than in 2011.

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How Respondents Learn of Healthcare Services (Question 5)

2014 N= 165

2011 N= 252

The most frequent method of learning about available services at Madison Valley Medical

Center was “Word of mouth/reputation” at 63.6% (n=105). “Friends/family” was the second

most frequent response at 48.5% (n=80) and “Newspaper” was reported at 42.4% (n=70).

Respondents could select more than one method so percentages do not equal 100%.

2011 2014

Method Count Percent Count Percent

Word of mouth/reputation1 194 77.0% 105 63.6%

Friends/family Not asked in 2011 80 48.5%

Newspaper Not asked in 2011 70 42.4%

Healthcare provider Not asked in 2011 52 31.5%

Mailings/newsletter2 48 19.0% 47 28.5%

Business directory 19 7.5% 14 8.5%

Presentations 17 6.7% 8 4.8%

County public health 8 3.2% 7 4.2%

Website/internet 17 6.7% 6 3.6%

Social media (Facebook, etc.) Not asked in 2011 0 0

Other 24 9.5% 10 6.1% 1Significantly fewer respondents indicated learning about health services via word of mouth in 2014

than in 2011. 2In 2014, significantly more respondents indicated learning of health services through

mailings/newsletter than in 2011.


- Auxiliary

- Employee

- Personal visit with hospital CEO

- Personal

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Cross Tabulation of Service Knowledge and Learning about Services

Analysis was done to assess respondents’ knowledge of services available at Madison Valley

Medical Center with how they learn about services available in their community. The chart

below shows the results of the cross tabulation. How respondents learned of healthcare services

was a multiple response item, thus totals do not add up to 100%.

KNOWLEDGE RATING OF MADISON VALLEY MEDICAL CENTER SERVICES

BY

HOW RESPONDENTS LEARN ABOUT HEALTHCARE SERVICES

Excellent Good Fair Poor Total

Word of mouth/reputation 26

(25%)

57

(54.8%)

18

(17.3%)

3

(2.9%) 104

Friends/family 16

(20%)

51

(63.8%)

11

(13.8%)

2

(2.5%) 80

Newspaper 13

(18.6%)

45

(64.3%)

12

(17.1%) 70

Healthcare provider 17

(32.7%)

29

(55.8%)

4

(7.7%)

2

(3.8%) 52

Mailings/newsletter 8

(17.0%)

30

(63.8%)

9

(19.1%)

47

Social media (Facebook,

etc.)

2

(14.3%)

11

(78.6%)

1

(7.1%)

14

Presentations 2

(25.0%)

6

(75.0%)

8

County public health 2

(28.6%)

4

(57.1%)

1

(14.3%)

7

Website/internet

3

(50%)

1

(16.7%)

2

(33.3%) 6

Other 2

(20%)

7

(70%)

1

(10%)

10

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Other Community Health Resources Utilized (Question 6)

2014 N= 165

2011 N= 252

Respondents were asked which community health resources, other than the hospital or clinic,

they had used in the last three years. “Pharmacy” was the most frequently utilized community

health resource cited by respondents at 78.2% (n=129). “Dentist” was also a highly utilized

resource at 51.5% (n=85) followed by “Vision services” at 25.5% (n=42). Respondents could

select more than one resource so percentages do not equal 100%.

2011 2014

Resource Count Percent Count Percent

Pharmacy 208 82.5% 129 78.2%

Dentist 109 43.3% 85 51.5%

Vision services 70 27.8% 42 25.5%

Public health 16 6.3% 14 8.5%

Senior Center 8 3.2% 6 3.6%

Counseling & Mental health 3 1.2% 4 2.4%

Hospice 0 0 1 0.6%

Other1 3 1.2% 9 5.5% 1Significantly more 2014 respondents indicated using “Other” health resources than in 2011.


- Billings Clinic

- Chiropractor (2)

- Dermatologist (2)

- E.R. [Emergency Room] and V.F.W. [Veterans of Foreign Wars]

- Health fair

- Physical therapy

16

Improvement for Community’s Access to Healthcare (Question 7)

2014 N= 165

2011 N= 252

Respondents were asked to indicate what they felt would improve their community’s access to

healthcare. Thirty-eight percent of respondents (n=62) reported that “More specialists” would

make the greatest improvement. Thirty-five percent of respondents (n=57) indicated they would

like “More primary care providers” and 20.6% (n=34) indicated “Greater health education

services” would improve access to care. Respondents could select more than one method so

percentages do not equal 100%.

2011 2014

Improvement Count Percent Count Percent

More specialists 82 32.5% 62 37.6%

More primary care providers1 52 20.6% 57 34.5%

Greater health education services 46 18.3% 34 20.6%

Improved quality of care 45 17.9% 33 20.0%

Outpatient services expanded hours2 20 7.9% 33 20.0%

Transportation assistance3 23 9.1% 30 18.2%

Telemedicine Not asked in 2011 12 7.3%

Cultural sensitivity 6 2.4% 5 3.0%

Interpreter services 3 1.2% 1 0.6%

Other 31 12.3% 15 9.1% 1Significantly more respondents indicated a need for more primary care providers in 2014 than in

2011. 2Expanded hours for outpatient services was cited significantly more often in 2014 than in 2011. 3Transportation assistance was indicated by significantly more respondents in 2014 than in 2011.


- At least one Internist

- Better ambulance service

- Cost effectiveness (4)

- Hospital consistency in nurses serving patients

- Mental health services

- Retention of good PCP’s [primary care providers]

17

Interest in Local Educational Classes/Programs (Question 8)

2014 N= 165

Respondents were asked if they would be interested in any educational classes/programs if

offered locally. The most highly indicated class/program indicated was “Fitness” at 30.3% of

respondents (n=50). “Nutrition” was selected by 29.7% of respondents (n=49) and “Women’s

health” followed at 26.1% (n=43). Respondents could select more than one method so

percentages do not equal 100%.

2014

Class/Program Count Percent

Fitness 50 30.3%

Nutrition 49 29.7%

Women’s health 43 26.1%

Weight loss 35 21.2%

First aid/CPR 29 17.6%

Living will 28 17.0%

Men’s health 28 17.0%

Diabetes 24 14.5%

Alzheimer’s 23 13.9%

Cancer 21 12.7%

Heart disease 18 10.9%

Mental health 13 7.9%

Grief counseling 13 7.9%

Support groups 8 4.8%

Smoking cessation 7 4.2%

Parenting 4 2.4%

Alcohol/substance abuse 4 2.4%

Childhood development 3 1.8%

Prenatal 0 0

Other 8 4.8%


- Aquatic center

- Dermatology/skin cancer signs

- Family planning

- Natural medicine classes

- Senior assistance with medical billing

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Survey Findings – Use of Healthcare Services

Needed/Delayed Hospital Care During the Past Three Years (Question 9)

2014 N= 156

2011 N= 242

Twenty-four percent of respondents (n=37) reported that they or a member of their household

thought they needed healthcare services but did not get it or had to delay getting it. Seventy-six

percent of respondents (n=119) felt they were able to get the healthcare services they needed

without delay and nine respondents chose not to answer this question.

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Reasons for NOT Being Able to Receive Services or Delay in Receiving Healthcare Services

(Question 10)

2014 N= 37

2011 N= 61

For those who indicated they were unable to receive or had to delay services (n=37), the reasons

most cited were: “It costs too much” (45.9%, n=17), “No insurance” (29.7%, n=11), and “My

insurance didn’t cover it” (27%, n=10). Respondents were asked to indicate their top three

choices, thus percentages do not total 100%.

2011 2014

Reason Count Percent Count Percent

It costs too much 29 47.5% 17 45.9%

No insurance 14 23.0% 11 29.7%

My insurance didn’t cover it 10 16.4% 10 27.0%

Too long to wait for an appointment 14 23.0% 8 21.6%

Too nervous or afraid 5 8.2% 5 13.5%

Could not get off work 3 4.9% 5 13.5%

Could not get an appointment 6 9.8% 4 10.8%

Didn’t know where to go 2 3.3% 4 10.8%

Don’t like doctors 7 11.5% 4 10.8%

Not treated with respect1 13 21.3% 2 5.4%

Office wasn’t open when I could go 0 0 2 5.4%

It was too far to go 3 4.9% 1 2.7%

Unsure if services were available 9 14.8% 1 2.7%

Had no one to care for the children 3 4.9% 0 0

Transportation problems 2 3.3% 0 0

Language barrier 0 0 0 0

Other 7 11.5% 7 18.9% 1Significantly fewer respondents delayed seeking medical care because they had not been treated with

respect in 2014 than in 2011.


- No one answers the phone

- Office wanted us to use the ER during daytime office hours - too expensive!

20

Utilization of Preventative Services (Question 11)

2014 N= 165

Respondents were asked if they had utilized any of the preventative services listed in the past

year. “Lab screenings” was selected by 60% of respondents (n=99). Fifty-six percent of

respondents (n=92) indicated they received a “Flu shot/other vaccinations” and 48.5% of

respondents (n=80) had a “Routine health checkup/Annual physical.” Respondents could select

all that apply, thus the percentages do not equal 100%.

2014

Service Count Percent

Lab screenings 99 60.0%

Flu shot/other vaccinations 92 55.8%

Routine health checkup/Annual physical 80 48.5%

Cholesterol check 78 47.3%

Routine blood pressure check 74 44.8%

Mammography 41 24.8%

Imaging screenings (Ultrasound, CT, etc.) 40 24.2%

Pap smear 30 18.2%

Colonoscopy 26 15.8%

Bone Density Screening 26 15.8%

Prostate (PSA) 22 13.3%

None 13 7.9%

Children’s checkup/Well Child 5 3.0%

Other 8 4.8%


- Blood screening

- Chiropractic

- ER

- Flu shot

- MRI

- Naturopath

- Physical Therapy

- Saliva tests for thyroid

- Swing bed

21

Desired Local Healthcare Services (Question 12)

2014 N= 165

2011 N= 252

Respondents were asked to indicate which healthcare professionals or services presently not

available would they use if available locally. Respondents indicated the most interest in having

both “Podiatry (foot care)” and “Naturopath” services available at 16.4% (n=27 each) followed

by “Counseling” at 9.1% (n=15) then “Home health care” at 6.7% (n=11). Respondents were

asked to select all that apply so percentages do not equal 100%.

2011 2014

Service Count Percent Count Percent

Podiatry (foot care) 48 19.0% 27 16.4%

Naturopath Not asked in 2011 27 16.4%

Counseling 13 5.2% 15 9.1%

Home health care 31 12.3% 11 6.7%

Durable Medical Equipment/home medical

equipment/oxygen 20 7.9% 8 4.8%

Transportation services Not asked in 2011 8 4.8%

Hospice Not asked in 2011 2 1.2%

Other 24 9.5% 12 7.3%


- Acupuncture

- Better pediatric services

- Dermatology (2)

- I would use all services if needed

- Lap swimming

- Mammogram

- Mental health professionals

- Nutrition

- Ophthalmology [eye care]

- Orthodontist [teeth and jaw]

- Orthopedic surgeon

- Vision

22

Hospital Care Received in the Past Three Years (Question 13)

2014 N= 162

2011 N= 241

Sixty-two percent of respondents (n=101) reported that they or a member of their family had

received hospital care (i.e. hospitalized overnight, day surgery, obstetrical care, rehabilitation,

radiology, or emergency care) during the previous three years. Thirty-eight percent (n=61) had

not received hospital services and three respondents chose not to answer this question.

23

Hospital Used Most in the Past Three Years (Question 14)

2014 N= 89

2011 N= 160

Of the 101 respondents who indicated receiving hospital care in the previous three years, 44%

(n=39) reported receiving care at Bozeman Deaconess in Bozeman. Forty percent of respondents

(n=36) went to Madison Valley Medical Center in Ennis and 6.7% of respondents (n=6) utilized

services from an “Other” facility. Twelve of the 101 respondents who reported they had been to

a hospital in the past three years did not indicate which hospital they had utilized.

2011 2014

Hospital Count Percent Count Percent

Bozeman Deaconess (Bozeman) 55 34.3% 39 44.0%

Madison Valley Medical Center (Ennis) 73 45.6% 36 40.4%

Billings Clinic (Billings)1 19 11.9% 3 3.4%

Barrett Hospital (Dillon) 4 2.5% 2 2.2%

St. Vincent Healthcare (Billings) Not asked in 2011 2 2.2%

St. James Healthcare (Butte) 3 1.9% 1 1.1%

Ruby Valley Medical Center (Sheridan) 6 3.8% 0 0

Other 0 0 6 6.7%

TOTAL 160 100% 89 100% 1 Significantly fewer respondents reported utilizing Billings Clinic during the past three years in 2014

than 2011.


- Bridger Orthopedic

- Fort Harrison (2)

- He first went to Bozeman because of the location of the accident; but due to large

oversight ended up back in the hospital in Ennis where he received excellent care

- Heart Institute in Missoula

- Mayo Medical Clinic in Phoenix, AZ

- Naples, FL

- St. Patrick Hospital in Missoula

24

Reasons for Selecting the Hospital Used (Question 15)

2014 N= 101

2011 N= 169

Of the 101 respondents who had a personal or family experience at a hospital within the past

three years, the primary reason given for selecting the facility used most often was “Prior

experience with hospital” at 49.5% (n=50). “Closest to home” was selected by 48.5% of the

respondents (n=49) and 43.6% (n=44) selected “Hospital’s reputation for quality.” Note that

respondents were asked to select the top three answers which influenced their choices; therefore

the percentages do not equal 100%.

2011 2014


Prior experience with hospital 80 47.3% 50 49.5%

Closest to home 97 57.4% 49 48.5%

Hospital’s reputation for quality1 35 20.7% 44 43.6%

Referred by physician2 44 26.0% 39 38.6%

Emergency, no choice 39 23.1% 33 32.7%

Recommended by family or friends3 8 4.7% 13 12.9%

Required by insurance plan4 3 1.8% 7 6.9%

VA/Military requirement 4 2.4% 5 5.0%

Closest to work 9 5.3% 2 2.0%

Cost of care 11 6.5% 2 2.0%

Other 8 4.7% 7 6.9% 1Significantly more respondents indicated choosing the hospital they used because of its reputation

for quality in 2014 than in 2011. 2In 2014, significantly more people received a physician referral than in 2011. 3Significantly more 2014 respondents selected a hospital based on a recommendation from family or

friends. 42014 respondents were significantly more likely to select a hospital based on insurance plan

requirements than they were in 2011.


- More doctors

- Quality and scope of services

- Rehab

- Self-referral

- Specialized surgery

- Weekend clinic not open

25

Cross Tabulation of Hospital and Residence

Analysis was done to examine where respondents utilized hospital services the most in the past

three years with where they live by zip code. The chart below shows the results of the cross

tabulation. Hospital location is across the top of the table and residents’ zip codes are along the

side.

LOCATION OF MOST OFTEN UTILIZED HOSPITAL BY RESIDENCE

Madison

Valley

Medical

Center

(Ennis)

Billings

Clinic

(Billings)

St. Vincent

Healthcare

(Billings)

Bozeman

Deaconess

(Bozeman)

Barrett

Hospital

(Dillon)

St. James

Healthcare

(Butte)

Other Total

Ennis

59729

30

(46.9%)

1

(1.6%)

1

(1.6%)

28

(43.8%)

1

(1.6%)

3

(4.7%) 64

McAllister

59740

4

(40%)

6

(60%) 10

Cameron

59720

1

(14.3%)

1

(14.3%)

4

(57.1%)

1

(14.3%) 7

Pony

59747

1

(50%)

1

(50%) 2

Norris

59745

1

(100%) 1

Alder

59710

1

(100%) 1

Virginia

City

59755

1

(100%) 1

West

Yellowstone

59758

1

(100%) 1

TOTAL 36

(41.4%)

2

(2.3%)

2

(2.3%)

39

(44.8%)

1

(1.1%)

1

(1.1%)

6

(6.9%)

87

(100%)

26

Cross Tabulation of Hospital and Reason Selected

Analysis was done to assess respondents’ most utilized hospital with why they selected that

hospital. The chart below shows the results of the cross tabulation. Reason hospital was selected

was a multiple response item, thus totals do not add up to 100%. Hospital location is across the

top of the table and reason for selection is along the side.

LOCATION OF MOST UTILIZED HOSPITAL BY REASONS HOSPITAL SELECTED

Madison

Valley

Medical

Center

(Ennis)

Billings

Clinic

(Billings)

St. Vincent

Healthcare

(Billings)

Bozeman

Deaconess

(Bozeman)

Barrett

Hospital

(Dillon)

St. James

Healthcare

(Butte)

Other Total

Prior experience

with hospital

19

(40.4%)

1

(2.1%)

23

(48.9%)

2

(4.3%)

1

(2.1%) 1

(2.1%) 47

Closest to home 32

(76.2%)

1

(2.4%)

9

(21.4%)

42

Hospital’s

reputation for

quality

11

(28.2%)

1

(2.6%)

1

(2.6%)

20

(51.3%)

2

(5.1%)

1

(2.6%)

3

(7.7%) 39

Referred by

physician

3

(8.6%)

2

(5.7%)

2

(5.7%)

22

(62.9%)

2

(5.7%)

4

(11.4%) 35

Emergency, no

choice

20

(74.1%)

6

(22.2%)

1

(3.7%) 27

Recommended by

family or friends

3

(27.3%)

6

(54.5%)

2

(18.2%) 11

Required by

insurance plan

1

(14.3%)

1

(14.3%)

4

(57.1%)

1

(14.3%) 7

VA/Military

requirement

1

(25%)

2

(50%)

1

(25%) 4

Cost of care

1

(50%)

1

(50%) 2

Closest to work 2

(100%)

2

Other 2

(28.6%)

3

(42.9%)

1

(14.3%) 1

(14.3%) 7

27

Primary Care Received in the Past Three Years (Question 16)

2014 N= 162

2011 N= 248

Ninety-four percent of respondents (n=153) indicated that they or someone in their household

had been seen by a primary care provider (such as a family physician, physician assistant, or

nurse practitioner) for healthcare services in the past three years. Six percent of respondents

(n=9) had not seen a primary care provider and three respondents chose not to answer this

question.

28

Location of Primary Care Provider (Question 17)

2014 N= 137

2011 N= 221

Of the 162 respondents who indicated receiving primary care services in the previous three

years, 62.8% (n=86) reported receiving care in Ennis. Thirty percent of respondents (n=41) went

to Bozeman and 3.6% of respondents (n=5) utilized primary care services in an “Other” location.

Twenty-five of the 162 respondents who reported they had utilized primary care services in the

past three years did not indicate where they received those services.

2011 2014

Clinic Count Percent Count Percent

Ennis 132 59.7% 86 62.8%

Bozeman 64 29.0% 41 30.0%

Dillon 7 3.1% 2 1.5%

Butte 1 0.5% 1 0.7%

Billings 1 0.5% 1 0.7%

Sheridan 6 2.7% 1 0.7%

Other 10 4.5% 5 3.6%

TOTAL 221 100% 137 100%


- Helena

- Idaho Falls, ID

- Naples, FL

- Salt Lake City, UT

29

Reasons for Selection of Primary Care Provider (Question 18)

2014 N= 153

2011 N= 236

Those respondents who indicated they or someone in their household had been seen by a primary

care provider within the past three years were asked to indicate why they chose that primary care

provider. “Closest to home” (50.3%, n=77) was the most frequently cited factor in primary care

provider selection followed closely by “Prior experience with the clinic” at 41.2% (n=63).

“Appointment availability” (30.7%, n=47) was the third most frequently cited factor.

Respondents were asked to select all that apply so the percentages do not equal 100%.

2011 2014


Closest to home 136 57.6% 77 50.3%

Prior experience with clinic 121 51.3% 63 41.2%

Appointment availability 64 27.1% 47 30.7%

Clinic’s reputation for quality 62 26.3% 42 27.5%

Recommended by family or friends 34 14.4% 30 19.6%

Length of waiting room time 17 7.2% 13 8.5%

Referred by physician or other

provider 27 11.4% 13 8.5%

Cost of care 15 6.4% 8 5.2%

Required by insurance plan 5 2.1% 7 4.6%

VA/Military requirement 7 3.0% 6 3.9%

Other 16 6.8% 10 6.5%


- Female provider

- Helped me get the care I desperately needed

- Only provider where I could see an Internist

- Personality of provider

- Prior experience (3)

30

Cross Tabulation of Primary Care and Residence

Analysis was done to examine where respondents went most often for primary care with where

they live by zip code. The chart below shows the results of the cross tabulation. Clinic location is

across the top of the table and residents’ zip codes are along the side.

LOCATION OF PRIMARY CARE PROVIDER MOST UTILIZED BY RESIDENCE

Ennis Bozeman Sheridan Butte Other Total

Ennis

59729

60

(65.9%)

28

(30.8%)

1

(1.1%)

2

(2.2%) 91

McAllister

59740

13

(76.5%)

4

(23.5%) 17

Cameron

59720

6

(50%)

4

(33.3%)

2

(16.7%) 12

Virginia City

59755

2

(66.7%)

1

(33.3%) 3

Norris

59745

1

(50%)

1

(50%) 2

Pony

59747

1

(50%)

1

(50%) 2

West Yellowstone

59758

1

(50%)

1

(50%) 2

Harrison

59735

1

(100%) 1

Alder

59710

1

(100%) 1

TOTAL 83

(63.4%)

41

(31.3%)

1

(0.8%)

1

(0.8%)

5

(3.8%) 131

31

Cross Tabulation of Clinic and Reason Selected

Analysis was done to examine where respondents went most often for primary care services with

why they selected that clinic/provider. The chart below shows the results of the cross tabulation.

Reason clinic/provider was selected was a multiple response item, thus totals do not add up to

100%.

LOCATION OF PRIMARY CARE PROVIDER BY REASONS CLINIC SELECTED

En

nis

Bil

lin

gs

Boze

man

Sh

erid

an

Dil

lon

Bu

tte

Oth

er

Tota

l

Closest to

home

66

(95.7%)

2

(2.9%)

1

(1.4%) 69

Prior

experience

with clinic

42

(73.7%)

13

(22.8%)

1

(1.8%)

1

(1.8%) 57

Appointment

availability

39

(90.7%)

2

(4.7%)

1

(2.3%)

1

(2.3%) 43

Clinic’s

reputation for

quality

23

(59%)

13

(33.3%)

1

(2.3%)

2

(5.1%) 39

Recommended

by family or

friends

12

(46.2%)

12

(46.2%)

1

(3.8%)

1

(3.8%) 26

Length of

waiting room

time

10

(83.3%)

2

(16.7%) 12

Referred by

physician or

other provider

3

(25%)

1

(8.3%)

7

(58.3%)

1

(8.3%) 12

Required by

insurance plan

1

(14.3%)

2

(28.6%)

2

(28.6%)

2

(28.6%) 7

Cost of care 4

(66.7%)

1

(16.7%)

1

(16.7%) 6

VA/Military

requirement

1

(25%)

3

(75%) 4

Other 2

(20%)

7

(70%)

1

(10%) 10

32

Use of Healthcare Specialists during the Past Three Years (Question 19)

2014 N= 146

2011 N= 242

Eighty-six percent of respondents (n=125) indicated they or a household member had seen a

healthcare specialist during the past three years. Fourteen percent (n=21) indicated they had not

seen a specialist and nineteen respondents chose not to answer this question.

33

Type of Healthcare Specialist Seen (Question 20)

2014 N= 125

2011 N= 190

The respondents (n=125) saw a wide array of healthcare specialists in the past three years. The

most frequently indicated specialist was a “Dentist” at 64.8% of respondents (n=81) having

utilized their services. “Dermatologist” was the second most utilized specialist at 39.2% (n=49)

and “Orthopedic surgeon” was third at 36% (n=45). Respondents were asked to choose all that

apply so percentages do not equal 100%.

2011 2014

Healthcare Specialist Count Percent Count Percent

Dentist 103 54.2% 81 64.8%

Dermatologist 60 31.6% 49 39.2%

Orthopedic surgeon1 48 25.3% 45 36.0%

Ophthalmologist Not asked in 2011 44 35.2%

Physical therapist2 37 19.5% 39 31.2%

Radiologist3 24 12.6% 29 23.2%

OB/GYN 53 27.9% 26 20.8%

Chiropractor 31 16.3% 24 19.2%

Gastroenterologist 31 16.3% 24 19.2%

Cardiologist 36 18.9% 20 16.0%

General surgeon 22 11.6% 14 11.2%

Neurologist4 7 3.7% 13 10.4%

Urologist 15 7.9% 12 9.6%

ENT (ear/nose/throat) 15 7.9% 9 7.2%

Oncologist 22 11.6% 9 7.2%

Podiatrist 12 6.3% 8 6.4%

Rheumatologist 6 3.2% 8 6.4%

Endocrinologist 5 2.6% 7 5.6%

Speech therapist 2 1.1% 5 4.0%

Allergist 12 6.3% 4 3.2%

Mental health counselor 4 2.1% 4 3.2%

Neurosurgeon 6 3.2% 4 3.2%

Pulmonologist 11 5.8% 3 2.4%

Occupational therapist 5 2.6% 2 1.6%

Pediatrician 9 4.7% 2 1.6%

Dietician 4 2.1% 2 1.6%

Psychiatrist (M.D.) 2 1.1% 1 0.8%

Social worker 0 0 1 0.8%

Geriatrician 2 1.1% 1 0.8%

Psychologist 3 1.6% 0 0

Substance abuse counselor 0 0 0 0

Other 14 7.4% 10 8.0%

Question 20 continued on following page…

34

Question 20 continued…

1Significantly more 2014 respondents have visited an orthopedic surgeon in the past three years. 2In 2014, significantly more people reported seeing a physical therapist in the past three years. 3Significantly more people in 2014 reported seeing a radiologist in the past three years. 4Significantly more 2014 respondents visited a neurologist in the past three years.


- Anesthesiologist

- Diabetes nurse

- Interventional neuroradiology

- Naturopath (3)

- Nutritionist

- PA [Physician’s Assistant]

- Sleep apnea doctor

- VAMC [Veterans Affair Medical Center] in Fort Harrison

- Vascular surgeon

- Wound specialist

35

Location of Healthcare Specialist (Question 21)

2014 N= 125

2011 N= 190

Of the 125 respondents who indicated they saw a healthcare specialist in the past three years,

69.6% (n=87) saw one in Bozeman. “Other” locations were utilized by 36.8% (n=46) of

respondents for specialty care and Ennis was reported by 35.2% (n=44). Respondents could

select more than one location; therefore percentages do not equal 100%.

2011 2014

Location Count Percent Count Percent

Bozeman Deaconess (Bozeman) 117 61.6% 87 69.6%


(Ennis) 29 15.3% 44 35.2%

Billings Clinic (Billings) 14 7.4% 13 10.4%

St. James Healthcare (Butte) 10 5.3% 6 4.8%

St. Vincent Healthcare (Billings) Not asked in 2011 4 3.2%

Barrett Hospital (Dillon) 10 5.3% 2 1.6%

Ruby Valley Medical Center

(Sheridan) 1 0.5% 0 0

Other 70 36.8% 46 36.8%


- Bridger Clinic in Bozeman

- Bridger Orthopedic (3)

- Bozeman (5)

- Chiropractic offices in Ennis & Belgrade

- Concord, MA

- Dentist office in Sheridan

- Dillon

- Mayo Hospital Clinic in Phoenix, AZ

- Naples, FL

- Portland, OR

- Private practice in Bozeman

- Rogers Dermatology

- Salt Lake City, UT

- Scottsdale Healthcare

- Scripps Institute

- Springfield, MO

- Swedish Medical Center

36

Overall Quality of Care at Madison Valley Medical Center (Question 22)

2014 N= 165

2011 N= 252

Respondents were asked to rate a variety of aspects of the overall care provided at Madison

Valley Medical Center using the scale of 4=Excellent, 3=Good, 2=Fair, 1=Poor, and “Don’t

know.” The sums of the average scores were then calculated with “Immunizations/vaccinations,”

“Laboratory,” and “Occupational/speech therapy” receiving the top average scores of 3.6 out of

4.0. The total average score was 3.6, indicating the overall services of the hospital to be

“Excellent” to “Good.”

2014 Excellent

(4)

Good

(3)

Fair

(2)

Poor

(1)

Don’t

know

No

Ans. N Avg

Immunizations/

vaccinations 53 28 1 1 61 21 165 3.6

Laboratory 69 39 4 0 40 13 165 3.6

Occupational/speech

therapy 5 2 1 0 126 31 165 3.6

Imaging (x-ray,

ultrasound, CT, etc.) 45 35 2 0 65 18 165 3.5

Pediatrics (children's

health) 2 2 1 1 127 32 165 3.5

Clinic 65 55 10 4 22 9 165 3.4

Emergency room 45 37 10 3 53 17 165 3.3

Health fair 26 36 6 0 76 21 165 3.3

Physicals 22 38 2 1 77 25 165 3.3

Visiting specialists

(Cardiology, Orthopedics,

etc.)

27 9 1 1 101 26 165 3.3

Skilled nursing care 18 23 3 0 99 22 165 3.2

Diabetic counseling 9 7 4 1 111 33 165 3.1

Physical therapy 18 18 8 1 91 29 165 2.8

TOTAL 404 329 53 13 3.6

Question 22 continued on following page…

37


2011 Excellent

(4)

Good

(3)

Fair

(2)

Poor

(1)

Don’t

know

No

Ans. N Avg

Skilled nursing care 51 24 7 2 147 21 252 3.6

Pediatrics (children's

health) 4 6 2 3 208 29 252 3.5

Health fair 50 46 4 2 125 25 252 3.4

Imaging (x-ray,

ultrasound, CT, etc.) 62 43 7 3 113 24 252 3.4

Immunizations/

vaccinations 63 39 6 4 119 21 252 3.4

Laboratory 101 57 12 2 64 16 252 3.4

Emergency room 65 43 13 5 110 16 252 3.3

Diabetic counseling 6 8 4 0 207 27 252 3.1

Physical therapy 46 13 3 3 161 26 252 2.7

TOTAL 448 279 58 24 3.5

38

Survey Findings – Personal Health

Prevalence of Depression (Question 23)

2014 N= 152

Respondents were asked to indicate if there were periods of at least three consecutive months in

the past three years where they felt depressed on most days, although they may have felt okay

sometimes. Thirteen percent of respondents (n=20) indicated they had experienced periods of

feeling depressed and 86.8% of respondents (n=132) indicated they had not. Thirteen

respondents chose not to answer this question.

39

Sought Appropriate Resources for Depression (Question 24)

2014 N= 19

Of the 20 respondents who indicated there were periods of at least three consecutive months in

the past three years where they felt depressed on most days, 36.8% (n=7) indicated they sought

appropriate care or resources to address their needs. Forty-seven percent of respondents (n=9)

did not seek care and 15.8% (n=3) ‘Didn’t know where resources were available.’ One person

chose not to indicate whether they sought services.

40

Physical Activity (Question 25)

2014 N= 154

Respondents were asked to indicate how frequently they had physical activity for at least twenty

minutes over the past month. Fifty-three percent of respondents (n=81) indicated they had

physical activity of at least twenty minutes “Daily” and 30.5% (n=47) indicated “2-4 times per

week.” Nearly twelve percent (n=18) indicated “3-5 times per month” and 2% (n=3) reported

“No physical activity.” Eleven respondents chose not to answer this question.

41

Survey Findings – Cost and Health Insurance

Cost and Prescription Medications (Question 26)

2014 N= 158

Respondents were asked to indicate if, during the last year, medication costs had prohibited them

from getting a prescription or taking their medication regularly. Fifteen percent of respondents

(n=23) indicated that, in the last year, cost had prohibited them from getting a prescription or

taking their medication regularly. Eighty-five percent of respondents (n=135) indicated that cost

had not prohibited them, and seven respondents chose not to answer this question.

42

Insurance and Healthcare Costs (Question 27)

2014 N= 150

2011 N= 227

Respondents were asked to indicate how well they felt their health insurance covers their

healthcare costs. Forty-five percent of respondents (n=67) indicated they felt their insurance

covers a “Good” amount of their healthcare costs. Twenty-five percent of respondents (n=38)

indicated they felt their insurance is “Excellent” and 24.7% of respondents (n=37) indicated they

felt their insurance coverage was “Fair.” Fifteen respondents did not answer this question.

43

Medical Insurance (Question 28)

2014 N= 136

2011 N= 199

Respondents were asked to indicate what type of medical insurance covers the majority of their

medical expenses. Thirty-nine percent (n=53) indicated they have “Medicare” coverage. Twenty-

two percent (n=30) indicated they have “Employer sponsored” coverage and “Private

insurance/private plan” was indicated by 12.5% of respondents (n=17). Twenty-nine respondents

chose not to answer this question.

2011 2014

Insurance Type Count Percent Count Percent

Medicare 79 39.8% 53 39.0%

Employer sponsored 51 25.6% 30 22.1%

Private insurance/private plan 49 24.6% 17 12.5%

Health Insurance Marketplace Not asked in 2011 12 8.8%

None/Pay out of pocket Not asked in 2011 6 4.4%

VA/Military 5 2.5% 6 4.4%

Health Savings Account 2 1.0% 2 1.5%

Healthy MT Kids 3 1.5% 2 1.5%

Medicaid 1 0.5% 1 0.7%

State/other 1 0.5% 1 0.7%

Agricultural Corp. Paid 1 0.5% 0 0

Other 7 3.5% 6 4.4%

TOTAL 199 100% 136 100%


- Employer pays half of insurance

- SSI [Supplemental Security Income]

44

Barriers to Having Health Insurance (Question 29)

2014 N= 6

2011 N= 21

Those respondents who indicated they did not have medical insurance were asked to indicate

why they did not. Sixty-seven percent (n=4) reported they did not have health insurance because

they could not afford to pay for it and 33.3% (n=2) indicated “Employer does not offer

insurance.” Respondents were asked to mark all answers that applied, thus the percentages do

not equal 100%.

2011 2014


Cannot afford to pay for medical insurance 17 81.0% 4 66.7%

Employer does not offer insurance 5 23.8% 2 33.3%

Choose not to have medical insurance 5 23.8% 1 16.7%

Other 3 14.3% 1 16.7%


- Employer covers me, but I can’t afford the family

45

Awareness of Health Payment Programs (Question 30)

2014 N= 135

2011 N= 214

Respondents were asked to indicate their awareness of programs that help people pay for

healthcare bills. Forty-five percent of respondents (n=61) indicated they were aware of these

types of programs, but did not qualify to utilize them. Twenty-nine percent (n=39) indicated that

they were not aware or did not know of these programs and 13.3% of respondents (n=18)

indicated they were aware of and utilized health payment assistance programs. Thirty

respondents chose not to answer this question.

46

Awareness of Health Insurance Enrollment Programs (Question 31)

2014 N= 128

Respondents were asked to indicate their awareness of programs that help people enroll in health

insurance plans. Forty-three percent of respondents (n=55) indicated they were aware of these

types of programs, but did not utilize them. Twenty-seven percent (n=34) indicated that they

were not aware or did not know of these programs and 20.3% of respondents (n=26) indicated

they were aware of and utilized health insurance enrollment. Thirty-seven respondents chose not

to answer this question.

47

VI. Key Informant Interview Methodology

Six individual key informant interviews were conducted by telephone in May, June, and July

2014. Key informant participants were identified as people living in Madison Valley Medical

Center’s service area.

Six people participated in the six key informant interviews. The interviews were designed to

represent various consumer groups. Each interview lasted up to 30 minutes in length and

followed the same line of questioning in each session (Appendix F). The questions and

discussions during the key informant interviews were led by Sarah Devitt with the Montana

Office of Rural Health.

Key Informant Interview notes can be found in Appendix G of this report.

48

VII. Summary of Key Informant Interview Findings

The following key findings, themes, and health needs emerged from the responses which

participants gave to the line of questioning found in Appendix F.

Improve health of the community:

More awareness of local resources such as walking trails, the community garden, and

farmer’s market

Fresh fruits and vegetables

Employee wellness programs

Having a public pool

More mental health services available

Having fewer bars

Most important local healthcare issues:

Maintaining healthcare professionals, specifically family physicians

Mental health

Prescription drug abuse

Participants voiced their concerns about Ennis’s rapidly growing population and the

lack of senior services available for seniors including transportation and home health

care

Finding volunteers for pre-hospital care such as EMTs

Drug and alcohol abuse

Depression

Obesity

Opinion of hospital services:

Doctors, nurses, and physician assistants are of high-quality

The hospital provides a higher level of care than most rural areas

Excellent quality of care at Madison Valley Medical Center

Many specialty services are available at Madison Valley Medical Center that are not

commonly found in other rural hospitals

Opinion of local services:

Participants are very satisfied with the nursing homes in Ennis and Sheridan

There is a great variety of local services and resources that support community

member’s ability to live healthy lifestyles

49

Reasons to leave the community for healthcare:

Mental health services such as counseling

To seek care from specialty doctors

Needed healthcare services in the community:

Pediatric care

Mental health services such as counseling

Women’s health

Psychiatric care in the hospital

Home health care

Transportation services for the elderly

Youth-targeted nutrition programs

Assistance programs for single parents

Participants understood that some specialty services would not be financially feasible

to have in their rural community

50

VIII. Summary

One hundred sixty-five surveys were completed in Madison Valley Medical Center’s service

area for a 24% response rate. Of the 165 returned, 67.3% of the respondents were females,

78.9% were 56 years of age or older, and 53.5% are retired.

Respondents rated the overall quality of care at the hospital as excellent, scoring 3.6 out of 4.0 on

a scale of 4.0 being excellent and 1.0 being poor.

Most respondents rated the Ennis area as either healthy (46.3%) or somewhat healthy (43.7%).

Significantly fewer respondents rated the Ennis area as very healthy or healthy than in 2011.

Respondents indicated their top three health concerns were: alcohol abuse/substance abuse

(63%), cancer (38.2%), and overweight/obesity (29.1%). Significantly more respondents

identified overweight/obesity to be a concern than in 2011.

When respondents were asked which health related educational programs or classes they would

be most interested in, the top choices were: fitness (30.3%), nutrition (29.7%), and women’s

health (26.1%).

Overall, the respondents within Madison Valley Medical Center’s service area are seeking

hospital care at a rate that is typically seen in rural areas.

The majority of participants appeared to have very favorable opinions of the services with most

praising the care received. Participants were appreciative of the care available while identifying

additional services or needs.

In summary, respondents report support for local healthcare and many prefer to seek care locally

whenever possible for convenience and out of trust for local providers.

51

Appendix A – Steering Committee Members

Steering Committee – Name and Organization Affiliation

1. John Bishop – CEO, Madison Valley Medical Center

2. Janine Clavadetscher – Registered Nurse & Clinical Coordinator, Madison Valley

Medical Center

3. Colleen Hill – Auxiliary Volunteer, Madison Valley Medical Center

4. Lilly Bowery – Public Health Nurse, Madison County Public Health Department

5. Lacey Hanson – Licensed Clinical Professional Counselor, Owner of Soul Journey, a

private practice offering a variety of counseling services

6. Melinda Tichenor –Laboratory Manager, Madison Valley Medical Center

52

Appendix B – Public Health and Special Populations Consultation

Public Health and Populations Consultation Worksheet

1. Public Health

a. Name/Organization

Lilly Bowery – Public Health Nurse, Madison County Public Health Department

b. Date of Consultation

First Steering Committee Meeting: May 12, 2014

c. Type of Consultation (Interview, Steering Committee, Focus Group, etc.)

Steering Committee

d. Input and Recommendations from Consultation

- Our community is small enough that if even one child is not following their

immunization schedule, our immunization rate falls considerably.

- We have a DUI taskforce in our area because there are many car accidents involving

alcohol.

- Alcohol use is a problem as shown in the secondary data analysis as well.

2. Populations Consultation (a leader or representative of populations such as medically

underserved, low-income, minority and/or populations with chronic disease)

Population: Seniors


Colleen Hill – Auxiliary Volunteer, Madison Valley Medical Center

John Bishop – CEO, Madison Valley Medical Center




Steering Committee


- Many seniors have no means of transportation, and more services should be available

in our community regarding their transportation needs.

- More physical activity opportunities might encourage our community to be more

active. Maybe there should be a Community Recreational Center, with a swimming

pool that would benefit seniors and people who are not very active.

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Population: Youth


Lacey Hanson – Licensed Clinical Professional Counselor, Soul Journey




Steering Committee


- There needs to be more resources available for our youth population regarding teen

pregnancy and sexual health needs.

Population: Mental Health


Lacey Hanson – Licensed Clinical Professional Counselor, Soul Journey




Steering Committee


- There may be a need for more mental health outreach and awareness efforts,

specifically targeting depression.

- Suicide is often more common when the weather starts to warm up.

- It’d be helpful to know if people are seeking mental health services and, if they

aren’t, what is preventing them from doing so? It is important to identify the barriers

of seeking mental health services so we can improve access to these services.

Population: Low-Income, Underinsured


John Bishop – CEO, Madison Valley Medical Center




Steering Committee


- Madison Valley Medical Center hopes to implement a drug pricing program called

“340B” so patients can purchase their prescriptions at cost rather than at mark-up

value. This would help people to better afford their medications.

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Appendix C – Survey Cover Letter

55

Appendix D – Survey Instrument

61

Appendix E – Responses to Other and Comments

2. In the following list, what do you think are the three most serious health concerns in our

community?

Affordable healthcare for seniors

Health education

Highway accidents

Hypertension

Lack of access to local specialists and specialized services

Lack of health education

Preventative care

3. Select the three items below that you believe are most important for a healthy

community:

Senior Center

5. How do you learn about the health services available at Madison Valley Medical Center?

Auxiliary

Employee

Personal visit with hospital CEO

Personal

6. Which community health resources, other than the hospital or clinic, have you used in

the last three years?

Billings Clinic

Chiropractor (2)

Dermatologist (2)

E.R. [Emergency Room] and V.F.W. [Veterans of Foreign Wars]

Health fair

Physical therapy

7. In your opinion, what would improve our community's access to healthcare?

At least one Internist

Better ambulance service

Cost effectiveness (4)

Hospital consistency in nurses serving patients

Mental health services

Retention of good PCP’s [primary care providers]

8. If any of the following classes/programs were made available to the Ennis community,

which would you be most interested in attending?

Aquatic center

Dermatology/skin cancer signs

Family planning

Natural medicine classes

Senior assistance with medical billing

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10. If yes, what were the three most important reasons why you did not receive healthcare

services?

No one answers the phone

Office wanted us to use the ER during daytime office hours - too expensive!

11. Which of the following preventative services have you used in the past year?

Blood screening

Chiropractic

ER

Flu shot

MRI

Naturopath

Physical Therapy

Saliva tests for thyroid

Swing bed

12. What additional healthcare services would you use if available locally?

Acupuncture

Better pediatric services

Dermatology (2)

I would use all services if needed

Lap swimming

Mammogram

Mental health professionals

Nutrition

Ophthalmology [eye care]

Orthodontist [teeth and jaw]

Orthopedic surgeon

Vision

14. If yes, which hospital did your household use the MOST for hospital care?

Bridger Orthopedic

Fort Harrison (2)

He first went to Bozeman because of the location of the accident; but due to large

oversight ended up back in the hospital in Ennis where he received excellent care

Heart Institute in Missoula

Mayo Medical Clinic in Phoenix, AZ

Naples, FL

St. Patrick Hospital in Missoula

15. Thinking about the hospital you were at most frequently, what were the three most

important reasons for selecting that hospital?

More doctors

Quality and scope of services

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Rehab

Self-referral

Specialized surgery

Weekend clinic not open

17. Where was that primary healthcare provider located?

Helena

Idaho Falls, ID

Naples, FL

Salt Lake City, UT

18. Why did you select the primary care provider you are currently seeing?

Female provider

Helped me get the care I desperately needed

Only provider where I could see an Internist

Personality of provider

Prior experience (3)

20. What type of healthcare specialist was seen?

Anesthesiologist

Diabetes nurse

Interventional neuroradiology

Naturopath (3)

Nutritionist

PA [Physician’s Assistant]

Sleep apnea doctor

VAMC [Veterans Affair Medical Center] in Fort Harrison

Vascular surgeon

Wound specialist

21. Where was the healthcare specialist seen?

Bridger Clinic in Bozeman

Bridger Orthopedic (3)

Bozeman (5)

Chiropractic offices in Ennis & Belgrade

Concord, MA

Dentist office in Sheridan

Dillon

Mayo Hospital Clinic in Phoenix, AZ

Naples, FL

Portland, OR

Private practice in Bozeman

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Rogers Dermatology

Salt Lake City, UT

Scottsdale Healthcare

Scripps Institute

Springfield, MO

Swedish Medical Center

28. What type of medical insurance covers the majority of your household’s medical

expenses?

Employer pays half of insurance

SSI [Supplemental Security Income]

29. If you do NOT have medical insurance, why?

Employer covers me, but I can’t afford the family

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Appendix F – Key Informant Interview Questions

Purpose: The purpose of the key informant interview questions was to identify motives of local

residents when selecting healthcare providers and what services people need in their local

community. This market research will help determine the awareness of local programs and services,

as well as satisfaction or dissatisfaction with local services, providers, and facilities.

1. What would make your community a healthier place to live?

2. What do you think are the most important local healthcare issues?

3. What other healthcare services are needed in the community?

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Appendix G – Key Informant Interview Notes

Key Informant Interview #1

Thursday, May 22, 2014 1:00pm-1:30pm – Via phone call


- Better fresh fruits and vegetables.


- Our demographic consists mainly of a senior population. Having valuable healthcare

providers and the opportunity to get assistance is becoming increasingly demanding

due to our older population.


- I know there are some community members who think mental healthcare is needed,

but I do not think we need it. I also do not think the community has the ability to make

that happen because of our size.

- I actually think that pediatric care is going to be very important. For the most part, the

status of the hospital at this current time is proving a higher standard of care than most

places in the U.S. We have higher-quality doctors, physician assistants [Pas], and

nurses compared to most rural places. We have a great laboratory, imagery services

such as x-rays, and a lot of other services within our hospital that many communities

our size do not have.

- I think the biggest risk we face here is maintaining healthcare professionals. As a

nation, we are lacking family physicians, and I think that is the biggest risk for a

community our size. We want to avoid becoming a two-person Physician’s Assistant

hospital and instead grow and expand.

- I think our community needs to be reflective of the good fortune we have relative to

how the hospital is supported and funded. We are very lucky. Just look at other parts

of the state.

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Thursday, May 22, 2014 4:15pm-4:30pm – Via phone call


- It would be nice if more businesses understood the importance of wellness programs

for their employees.


- Prescription drug issues are one issue, and another local health issue would have to do

with the aging population. The fact that we are all getting older and we are not sure the

healthcare system is prepared for that.


- Having worked at Madison Valley Medical Center, I know that we have the big items

covered. I know that it would be difficult to justify resources, like money and people,

to address low population issues. For instance, I know of two people who need dialysis

but they can just go to Bozeman. I do not see the need for providing that service

because of the way the costs play out.

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Friday, May 23, 2014 11:30am-12:00pm – Via phone call

- What would make your community a healthier place to live?

- We have so many options if you want to be healthy. We have the farmer’s market, a

community garden… we have it all. We also have the wellness center, new sidewalks,

and we have Lions Club Park where I walk every day.

- Awareness of resources would make our community a healthier place to live. The

resources are here [Ennis], we just have to use them. We aren’t like Missoula or

Billings, where they have all sorts of fruit and vegetable stands around town, but we

do have resources. People just need to be aware of them.


- The hospital and their care providers are excellent.

- EMT’s see a different perspective of health due to the population served. Finding

volunteers is a huge issue right now. Finding a crew for the ambulance is very

difficult. The volunteers all have lives, so how can they volunteer during the day? We

hate the thought of a paid service, but if we want to have a response rate of around five

minutes when responding to a call, we might have to go that route.

- It is cooler to be a fireman than an EMT, which is why we have a hard time getting

volunteers. Just ask the kids at school, everyone wants to be a firefighter but no one

wants to be an EMT.

- I would say the issues involving the pre-hospital time frame are a concern. The needs

are pre-hospital verses in-the-hospital care.

- Madison Valley Medical Center provides many specialty services, and has access to

many things, like life-flights. Once a patient gets to the hospital, our concerns lessen

because they are in good hands.


- Other than pre-hospital volunteers, I don’t know what exactly is available for

psychotic type stuff. But, I think a bit differently than the normal community member.

I think about what my patients need, and my answers reflect that.

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Thursday, May 29, 2014 11:00am-1l:30am – Via phone call

- What would make your community a healthier place to live?

- I think mental health services would make our community a healthier place to live

because it is a big issue for sure.

- I hate to say this, but having fewer bars in town would also improve the community’s

health. I think Montana is known for this [excessive drinking].

- Ennis only has about 800 people, and there are at least four bars I can think of

off-hand. And in small communities, there isn’t much to do. With my

experience, there is a major alcohol and drug problem in this area.

- I think there is a lot of depression, but maybe not so much now because the sun

is shining. I think counseling is great, and wish there were more counseling

services here in Ennis. Many people have to go to Bozeman when seeking

counseling services, and usually have to wait awhile to get appointments.


- Mental health. We have a good hospital. We have some very good doctors. We are

pretty much a retirement community so elderly-focused healthcare issues are

important.

- Again, from what I’m aware of, there is alcohol and drug abuse in our area, so that is a

big, big issue.

- To a certain degree, obesity could be considered another issue.


- Again, mental health services. Counseling, definitely. They will never get a rehab

facility in here, so mainly counseling. It might be useful if the Emergency Room had a

Psych Evaluator.

- Suicide is a big issue everywhere, especially in Montana. From what I have heard,

there might be some importance around getting a person in the ER for a psych

evaluation. If a patient comes in, and needs a psychological evaluation, but there are

no services for them, what are the doctors to do with the patient? Keep them in the

Emergency Room? Send them home? It would be a tough call.

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Friday, June 29, 2014 1:45pm-2:00pm – Via phone call


- Well we have a new hospital, that’s really good.

- One thing they are trying to get here, which would be great, would be a pool. You

can’t really swim in a river.

- We could benefit from mental health services.


- I work at a nursing home so I think that senior services that follow up on people that

are living at home would be very beneficial for our community. I think that senior

services are really important. We are getting to be an older retired community, and we

need to take care of our people.


- Mental Health Services.

- We have somebody that comes in and does colonoscopies and MRIs once a month or

so, but no one comes to do mammograms. It doesn’t sound like a big deal, traveling to

Bozeman to do it, but it actually is, and sometimes difficult to do it in a timely fashion.

- We do have a number of healthcare providers who come over to Ennis, so that’s good.

I would say some home care is needed, because that is hard to come by here. I had a

lady call me the other day and asked me to check on her mom…its tough, because I

hate to say it, but that’s not really my responsibility.

- Then, if I were to do it for her I would have to do it for everyone who called

and asked.

- I think it would be nice if there was a nurse that worked in the town that would

do home visits. The tough part would be finding the funds for this kind of

program.

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Friday, July 1, 2014 10:45am-11:00am – Via phone call


- I would say better mental health services. There have been a number of suicides and

mental health issues for the last number of years and if we can do something to

decrease that.

- We have actually created the Madison County Mental Health Counsel.

- We are also working on additional walking paths and side-walks so that people do not

have to walk on the streets.


- I would say senior services. We have two very good nursing homes, one in Ennis and

the other in Sheridan, but our Ennis population is increasingly getting older.

- In the summer time we have folks who come and stay, but most of our true community

members are retired, and they will all end up in the nursing home.

- Getting transportation for those older folks, who are trying to get to the doctor, I’m

concerned about their options for transportation.


- Besides mental health and transportation for the elderly, I think most of the schools do

a pretty good effort, but early childhood nutrition needs to be more of a focus and

concern.

- There needs to be an emphasis on nutrition in kindergarten through 12th grade.

- Although the majority of our population is full of aging folks, we also have a

number of service oriented folks, and some of them are single parents who

make barely over minimum wage. I get concerned about how they financially

take care of their children. I know firsthand, I’ve been in that situation.

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Appendix H – Secondary Data

County Profile

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Economic Impact Assessment

Demographic Trends and Economic Impacts:

A Report for Madison Valley Medical Center William Connell

Brad Eldredge Ph.D.

Research and Analysis Bureau

Montana Department of Labor and Industry

Introduction

This report responds to requests by MHA for information on Madison County’s demographics

and the economic impact of the hospital sector in Madison County. Section I looks at the

demographic profile of Madison County. Section II presents the results of an input-output analysis of

the impact of Madison Valley Medical Center on the county’s economy.

Section I Age Demographics

The 2010 Census reported that there were 7,691 residents of Madison County. The

breakdown of these residents by age is presented in Figure 1. Madison County’s age profile is similar

to that of many rural counties in Montana. In 2010, baby boomers were between the ages of 45 and

60 and their presence is evident in the graph. Following the baby boom came the baby bust, a period

of lower birth rates. The baby bust in many rural Montana counties, including Madison County, is

exacerbated by the tendency for young people to leave these counties for more populated areas. Note

the scarcity of residents under 45 years old in Madison County.

Figure 1: Age Distribution of Madison County Residents

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Figure 2: Percent of the population by age groups, Madison County vs. Montana

Figure 2 shows how Madison County’s population distribution compares to Montana’s. A

careful examination of the graph and the underlying data reveals that, compared with the State as a

whole, Madison County has a much higher proportion of people 45 years old and above than the

state as a whole (57.0 percent vs. 44.2 percent). According to the 2010 Census, Madison County was

the eighth oldest county in the state, with a median age of 49.8. Given the concentration of older

people in Madison County, it is likely that healthcare utilization per capita is higher than in other

Montana counties, and will increase in the future as the baby boomers reach senior citizen status.

These demographic statistics are important when planning for healthcare provision both now, and in

the future.

Section II Economic Impacts

Businesses have an economic impact on their local communities that exceeds the direct

amount of people they employ or wages they pay. For example, individuals employed at Madison

Valley Medical Center spend a portion of their salary on goods and services produced in Madison

County, thus supporting jobs and income in those local businesses. Likewise, the hospital itself may

purchase goods and services from local suppliers. These businesses and employees then spend a

portion of their income on local goods and services which, in turn, supports other local jobs and

companies. Thus, the effect of one dollar of wages is multiplied as it circulates through the

community.

The amount of jobs and income in a local community attributable to a particular industry

sector can be determined by calculating its employment and income multipliers. Industries with the

highest multipliers generally are those who buy supplies, services, and labor from the local

community, sell products and services outside the local community, and pay a higher income to their

employees. Although hospitals in rural areas do not usually sell their services to non-residents, they

77

can still generate significant multiplier effects for their communities given that much of their funding

comes from outside the region, in the form of public and private insurance reimbursements. The

relatively high wages earned by hospital employees also tend to boost hospital’s multipliers.

Multipliers are calculated using a methodology called input-output modeling. The Research

and Analysis Bureau (R&A) uses IMPLAN software to do regional input-output modeling. The R&A

staff is able to correct the underlying IMPLAN data with confidential employment and earnings data

from the unemployment insurance system, which allows us to produce more accurate multipliers than

would otherwise be possible.

According to the input-output analysis, the hospital industry sector in Madison County has the

following multipliers:

Hospital Employment Multiplier = 1.40

Hospital Employee Compensation Multiplier = 1.37

Hospital output multipliers = 1.44

What do these numbers mean? The employment multiplier of 1.40 can be interpreted to mean

that for every job at Madison Valley Medical Center, another .40 jobs are supported in Madison

County. Another way to look at this is that if Madison Valley Medical Center suddenly went away,

about 21 additional non-hospital jobs would also be lost in the county (based on 2010 hospital

employment of 53). The employee compensation multiplier of 1.37 simply states that for every dollar

in wages and benefits paid to the hospital’s employees, another 37 cents of wages and benefits are

created in other local jobs in Madison County. Put another way, if Madison Valley Medical Center

suddenly went away, about $705,203 in additional annual wages would be lost from other jobs in the

county. Finally, the output multiplier indicates that for every dollar of goods and services produced

by Madison Valley Medical Center, output in the county increases by another 44 cents.

There are other potential economic impacts of hospitals beyond those identified by the input-

output analysis. Novak (2003)1 observes that “…a good healthcare system is an important indication

of an area’s quality of life. Healthcare, like education, is important to people and businesses when

deciding where to locate” (pg. 1). Thus, all other things being equal, the presence of a quality

healthcare system gives communities an advantage when competing for new businesses. An effective

healthcare system can also attract retirees to the community. Finally, healthcare may provide an

opportunity for young people to stay in the communities where they were raised, and still earn a high

wage. In areas of the state where economic opportunities are scarce, many hospitals are experiencing

shortages of qualified workers. In this situation, “growing your own” workforce may be a viable

option.

This study has sought to outline the economic importance of Madison Valley Medical Center

to the county’s economy. Tangible economic impacts have been presented, and intangible economic

development impacts have also been discussed. Any questions regarding the data or methodology can

be addressed to the author.

1 Novak, Nancy L. (2003) “Bridging the Gap in Rural Healthcare” The Main Street Economist: Commentary on the Rural

Economy, Center for the Study of Rural America: Federal Reserve Bank of Kansas City. September 2003

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